Provider Demographics
NPI:1053458091
Name:MCLAREN MEDICAL GROUP
Entity Type:Organization
Organization Name:MCLAREN MEDICAL GROUP
Other - Org Name:MCLAREN MEDICAL MANAGMENT, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-342-1040
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:2521 N ELMS RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-9426
Practice Address - Country:US
Practice Address - Phone:810-487-3640
Practice Address - Fax:810-487-3697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160D410050OtherBLUE CROSS BLUE SHIELD
MI=========OtherTAX ID
MI160D410050OtherBLUE CROSS BLUE SHIELD
MI0M28440Medicare ID - Type UnspecifiedMEDICARE